Psychosocial and individual factors affecting Quality of Life (QoL) in patients suffering from Achilles tendinopathy: A Systematic Review

doi:10.21203/rs.3.rs-1988834/v1

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Psychosocial and individual factors affecting Quality of Life (QoL) in patients suffering from Achilles tendinopathy: A Systematic Review

https://doi.org/10.21203/rs.3.rs-1988834/v1

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Background: Achilles tendinopathy (AT) is a joint condition that causes functional restrictions and pain. This condition negatively impacts patients' social connectedness and psychological well-being, reducing their quality of life (QoL). This review aims to summarise the current information on QoL in patients suffering from AT and share the reported individual factors that influence it.

Methods: A systematic review was conducted at PubMed, Cochrane, Google Scholar, and PsycINFO using tendinopathy and QoL-related keywords up to November 2021. Articles were included if they compared QoL to demographic factors such as age or gender, lifestyle factors (physical activity levels), comorbidity factors (diabetes, obesity), and/or a control group.

Results: 327 articles were reviewed; 21 met inclusion criteria. SF-36, EQ-5D, and VISA-A were the most common instrument used. All studies reported worse QoL in AT patients compared to a control group. When women were compared to men, women reported worse QoL. Education delivered by health care professionals improved QoL in patients with AT. Surgical AT interventions generally resulted in good to excellent outcomes, although results varied by age.

Conclusion: AT has a substantial impact on QoL. In AT patients, QoL is also influenced by specific individual factors, including gender and physical activity. To better comprehend AT, QoL data is a valuable tool that allows health care professionals to implement the most effective treatment plan.

Tendinopathy

Achilles tendon

quality of life

Individual factors

Human Factors

Psychosocial factors

Tendinopathy is the most prevalent tendon disorder that causes pain and dysfunction. Achilles tendinopathy (AT) is a clinical condition characterised by pain, tendon thickening and functional limitations of tendons and nearby structures, and impaired load-bearing capacity (1, 2). AT is one of the most frequent ankle and foot overuse injuries and a common cause of disability. It is usual in sports, especially lower limb tendinopathy in basketball and volleyball players, both recreational (ranging from 11.8–14.4%) and elite (32–45%) (3), and its prevalence is ever-increasing. AT has a poor prognosis, with a high incidence of chronicity and recurrence (4, 5). The annual number of tendon-related procedures performed worldwide has been increasing over time, reaching over €30 million in healthcare costs, which are approximately €140 billion (6). These injuries are associated with high health and socioeconomic costs, long-term postoperative rehabilitation, and loss of productivity (7).

It is not limited to the athletic populations. However, it is the most frequently reported injury related to the ankle and foot in different sports activities, with an incidence of 83.3 (per 1000 athlete-year exposure) (8) and an incidence rate of 2.35/1000 subjects in the general population (21–60 years) (9).

The aetiology of AT is multifactorial, including both intrinsic and extrinsic factors. The restricting pain and impaired load-bearing capacity associated with AT are assumed to decrease QoL. However, the economic and social relevance of the problem is not adequately considered as the prevalence of AT is underestimated, specifically for active populations, such as athletes and workers with high physical activity. Moreover, there is no direct evidence to support the effect on the patients' QoL, the effectiveness of treatment and the economic implications of work disability (10, 11).

There is a need for advanced therapies to improve the social reintegration of patients with diseases of weight-bearing joints. There are various treatment options available for AT, but they are not very effective in treating symptoms, as two-thirds of the patients with new-onset AT remain symptomatic at 1- year follow- up (1). Fast and good recovery is essential for these patients in terms of social relationships. That is why assessing how AT affects patients' identity, social activities, and perceived fitness levels is necessary to design effective disease management plans, but this information is not readily available for AT (2).

There is a need for a better understanding of AT and its treatments, as this condition is highly prevalent, impacts patients' daily lives, and has an economic impact due to work loss. This review aims to provide an international resource about the QoL of patients with AT and the associated factors such as demographic (age, sex, etc.) and individual factors (weight, physical activity, mental health, etc.) by analysing the available data in the literature.

Search Strategy

Original articles were identified and listed using electronic searches of PubMed, Google Scholar, Cochrane, and PsycINFO databases. The literature review start date was unrestricted, and the end date was November 29, 2021. The language was not considered an exclusion criterion. The keywords used were "Achilles tendinopathy" AND "quality of life" OR "life quality" OR "well-being" OR "well-being" OR "short form 36" OR "Achilles injury " OR "AT" OR "AT-QoL" OR "FAOS" OR "assessment of the quality of life" OR "quality metrics" OR "quality of well-being" OR "SF-36" and all shorter forms and variations. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA) were used to review the articles systematically (12).

Inclusion and exclusion criteria

The tag flowchart used for inclusion and exclusion can be seen in Fig. S1. Abstracts or articles reporting original data on QoL of AT patients were included. Inclusion criteria were QoL associated with one or more demographic factors (e.g., age, gender), lifestyle factors (e.g., level of physical activity), or comorbidity factors (e.g., diabetes, obesity) and compared with a reference population or control group (without AT). There was no age, gender, language, or year of publication restriction. This review excluded review articles, protocols for clinical trials, commentaries, editorials, proceedings summaries, or instrument development summaries.

Articles that described unspecified AT or any study that combined AT patients with other types of patients and did not separately include, analyse, or report AT-specific data (e.g., a population defined as "Tendinopathy") were also excluded. Three reviewers independently assessed each reference against the prespecified inclusion and exclusion criteria. Then a two-stage process was performed: first, titles and abstracts were checked, and second, full-text articles. Any queries and inter-rater discrepancies were resolved during a consensus meeting.

Data extraction

A single reviewer obtained the data for each eligible article using a pre-piloted extraction form. Study characteristics include publication details (author and year), participant characteristics (age, sex, body mass index [BMI], and the number of participants), instruments used, treatments applied in the intervention and control groups, and a summary of the main findings were extracted from the studies included. This data was then processed and reviewed by the three reviewers.

Quality appraisal

A modified version of the Cochrane quality appraisal tool (National Institute of Health 2014) was used to assess the article's quality (30). The assessment criteria are presented in Fig. 1. The strength of consistency between raters was not individually scored. With a maximum score of 13(high-quality) and zero(low quality), one point was allocated for each iteam. The studies were rated as low (0–4 points), moderate (5– 9 points), or high (10–13 points).

Literature search results

A total of 327 articles were initially identified (Fig. 2); 43 from PubMed, 112 from Cochrane, 172 from Google Scholar, and 0 from APA PsycINFO. A total of 87 articles were selected after the initial title and abstract screening and removal of duplicates. After manual searches and a full-text review, 37 articles were selected. The reference lists of all the included studies were examined to identify any additional studies that would meet the inclusion criteria. Twenty-one articles were included for final data extraction. All studies were labelled by the first author and year of first publication. The year of publication ranged from 2004 to 2021.

Characteristics of included studies

Study characteristic details are in Table 1. Most of the studies were conducted in the United States (n=5), followed by the United Kingdom (n=3), Australia (n=3), Netherlands (n=2) and Sweden (n=2), Germany (n=2), Denmark (n=1), Greece (n=1), Ireland (n=1) and Nigeria (n=1). Thirty-eight percent (n=8) of studies were cross-sectional in design, followed by other designs comprising 14.2% (n=3) qualitative design, 14.2% (n=3) retrospective, 9.5% (n=2) prospective, 4.76%(n=1) randomized controls trials, 4.76% (n=1) population-based cohorts, 4.76% (n=1) retrospective 4.76% (n=1) case-control, 4.76% (n=1) pilot study. The SF-36 (n=5)followed by FAOS (n=4) were the main instruments used to assess QoL. All articles were rated from moderate to high-quality; no study scored lower than 7 points. Sixteen articles were classified as high quality, and five studies (23.8%) were moderate.

Table 1

Study characteristics

References	Country	Study design	QoL instrument	Sample size	Mean Age	Gender distribution	Symptoms’ duration
Plinsinga et al	Australia	Case-control	EQ-5D, hospital anxiety and depression scale, TSK	75	AT: 45.7, Control: 41	AT: M: 17, F: 13, Control: M: 6, F:5
Ceravolo et al	Australia	Exploratory study	AQoL-8D	92		M: 49, F:43
Turner et al	Australia	Qualitative, interpretive description design	Semi-structured telephone interviews VISA-A	15	45.2, (n = 15)	M:8, F:7	8 months
Nørregaard et al	Denmark		Modification KOOS	53	42		28.5 months
Petersen et al	Germany	Prospective Randomised Study	SF-36	100	42.5	M:60, F:40	7.4 months
Knobloch et al	Germany	Cohort Study	FAOS	86		M:38, F:25	7 months
Dedes et al	Greece	Cross-sectional	UoP-PFQ	130		M:60, F:70
Mc Auliffe et al	Ireland	Qualitative interpretive description design	Semi-structured telephone interviews, VISA	8	40	M:6, F: 2	20.5 months
Opdam et al	Nether-lands	Retrospective	FAOS	59	50	M:18, F:27	45 months
Sleeswijk et al	Nether-lands	Cross-sectional	EQ-5D	80	50	M:39, F:41	15.7 months
Aiyegbusi et al	Nigeria	Cross-sectional	VISA-A	345	30.3	M:257, F:45
Roos et al	Sweden	Randomised study	FAOS	44	46	M:21, F:23	5.5 months
Alfredson et al	Sweden	Pilot study	SF-36	24	M:45, F:50	M:13, F:11	18 months
Deans et al	UK	Prospective case series	FAOS	26	45.77	M:10, F:16
Maffulli et al	UK	Cross-sectional	VISA-A, EQ-5D	82	53.18	M:52, F:30
Mallows et al	UK	Qualitative interpretive description design	Semi-structured interviews		49.2	M:6, F:4	12.9 months
Martin et al	US	Cross-sectional	SF-36	44	58.2	M: 18, F:26
Chimenti et al	USA	Retrospective	SF-36	34	52.2		18 months
Corriga et al	USA	Cross-sectional	VISA-A	53	54.5	M:35, F:18	7 months
Phen et al	USA	Retrospective	SF-36	37	<60: 49.1, >60: 66.8	<60: M:5, F:16, >60: M:2, F:15
Chimeti et al	USA, Australia GermanyIndia, New Zeland, UK	Cross-sectional	TSK-11	442	36.3	M:191, F:251

AT: Achilles Tendinopathy; M: Male; F: Female; EQ-5D: EuroQol 5 dimensions; TSK: Tampa Scale for Kinesiophobia; AQoL-8D: assessment of the quality of life-8-dimension; VISA-A: Victorian Institute of Sport Assessment- Achilles questionnaire; KOOS: Knee Injury and Osteoarthritis Outcome Score; SF-36: Short Form 36; FAOS: Foot and Ankle Outcome Score; UoP-PFQ: University of Peloponnese Pain, Functionality and Quality of Life Questionnaire; TSK-11: Tampa Scale for Kinesiophobia-11

Characteristics of AT patients

The total population diagnosed with AT was 1772, of which 51.8% (n=918) were men and 48.2% were women. All the articles included in this review included both men and women. The mean number of AT patients per study was 84.3, with a sample size varying between 8 (13) and 442 (14). The mean age of patients included in the articles ranges from 30 to 66.8. Five articles investigated midportion AT, and four investigated insertional AT, three included patients with both midportion and insertional AT, and seven did not specify the location of AT. Concerning laterality, nine studies included both unilateral and bilateral AT, only one included unilateral AT, and eleven did not specify.

QoL in patients with AT versus Demographic Factors

Age showed a significant impact on AT patients’ QoL (15). Knobloch et al. (16) found that results were unfavourable among women older than 50. Weight, height and BMI did not show a significant impact. Compared with the control population, QoL was reported to be worse, especially in the physical function, role-physical, bodily pain, and social functioning domains (17–20) and all EQ-5D domains except self-care. Additionally, AT patients reported similar or worse QoL than individuals with other musculoskeletal diseases such as Rheumatoid Arthritis (RA), Osteoarthritis (OA), and fibromyalgia (2). Moreover, lower QoL was associated with one or more comorbidities, specifically, low back pain, high blood pressure, and diabetes (21). Chimenti et al. (14) found that patients identified as Hispanic or Latino presented higher kinesiophobia levels compared to the group identified as Caucasian. Concerning gender, women with AT reported worse QoL and did not benefit from eccentric or stretching training as much as men (16, 22). Conversely, one study found no difference between genders (23).

QoL in patients with AT versus Psychosocial Factors

Mc Auliffe et al. (13) found that AT affected patients as they felt a loss of self-esteem. Moreover, patients reported frustration as practitioners could not explain AT and had different opinions. AT patients also complain about their condition disrupting their daily activities, which affects their well-being and QoL (13, 24).

QoL and Physical Activity

It has been reported that AT is common in those who participate in sporting activities. However, it also affects less-active individuals. The studies included in this review show that QoL affects both patients with low and high activity levels as both groups show higher degrees of kinesiophobia. The loss of ability to exercise was reported to have a significant impact (25). However, being active in sports before AT has been reported significantly impact QoL after non-interventional treatment (26).

QoL and Educational Programs

Mallow et al. (25) conducted an interview and found that therapist understanding and empathy were essential for patients. Moreover, education was considered crucial, as well as good management of pain during exercise and a personalised approach with respect and understanding of each patient personal social circumstances and lifestyle. Patients also reported how AT has negatively impacted their self-identity and well-being and has caused body perception disturbance (27).

QoL and conservative and Surgical Interventions

Some studies showed that surgical intervention and its impact on QoL depended on demographic variables and only improved physical components. Chimenti et al. (14) reported that only the physical component showed improvement after a percutaneous ultrasonic tenotomy, while no significant changes were found in the mental component. Similarly, Deans et al. (2012) showed that although the physical domain improved after Autologous-conditioned Plasma (ACP) injections combined with exercise and therapeutic ultrasonography, patients’ QoL did not show significant improvement as patients reported that they had not been able to resume the activities they were used to before the injury. Patients with bilateral AT showed similar improvements after endoscopic treatment to unilateral patients except for activity in the daily living domain (28). Phen et al. (29) reported that patient satisfaction was lower among patients older than 60 years of age compared to younger patients.

Articles about AT usually assess the effectiveness of exercise and conservative and invasive interventions; however, not many consider the impact AT has on patients' QoL. As AT has been described to have a complex and often persistent nature, addressing other factors in addition to treatment effectiveness related to pain and function scores may be beneficial for a better comprehension of patients' needs and expectations. That is why we focus on the importance of QoL in AT patients. For example, QoL has been investigated in other musculoskeletal disorders such as knee osteoarthritis (KOA) (30).

AT is associated with psychological distress and poor QoL. Evidence from other musculoskeletal disorders suggests the importance of understanding the potential implications of QoL factors on essential aspects such as prognosis and treatment adherence.

This systematic review aimed to summarise the available data reporting QoL measures in AT patients. Twenty-one articles were identified as reporting information on QoL associated with one other factor (demographic, lifestyle, or comorbidity) between AT and control patients. All studies reported that AT patients had worse QoL, with some factors having a more significant adverse effect on QoL than others. For example, demographic factors such as gender and age influenced QoL. Women reported worse QoL than men. Moreover, comorbidities play an important role in the aggravation of AT symptoms and worse QoL.

Social connectedness and how patients interact with their healthcare experts also impact QoL. AT patients are at risk of developing depression, kinestophobia, and pain catastrophising. This feeling of hopelessness can moderately or intensely reduce their ability to perform daily tasks. Some studies suggest factors such as fear and self-efficacy are relevant for tendinopathy (19).

As shown in the articles included in this review, the Patient Reported Outcome Measures (PROMs) effectively assess how patients feel from their perspective. PROMs findings are of utmost importance for a more holistic treatment approach and to ensure health care services and procedures make a difference to a patient's health status and quality of life (31). However, creating and validating more PROMs specific to AT seems necessary.

Patients' social situations and context should be considered (24) when treating AT patients, as their improvement depends not only on their treatment as individuals but also as part of a socially connected environment. Moreover, healthcare providers need to reach some agreements and develop educational material to help patients deal with the frustration of not knowing about their conditions. Educating the patients is essential as it is critical to treatment adherence. Creating programs where patients participate in education and supervised exercise delivered by trained healthcare providers can improve pain intensity and QoL.

To the best of our knowledge, this is the first systematic review focusing on QoL in AT patients. Studies were manually reviewed after the adoption of a broader search strategy. This study highlights the importance of understanding the priority of a patient's perspective in clinical studies. Also, we aimed to collect information on the perception of QoL in AT patients and understand how individual factors and social determinants of health can affect it. The search was broad, including all articles that reported QoL in AT regardless of whether QoL was a primary endpoint, as long as additional selection criteria were met.

Limitations

There are limitations to acknowledge in this review. First, the description of sample size, data, etc. did not reflect the true methodological quality of the studies; thus, the high-quality scores should be interpreted with caution. Secondly, articles were included whether power analysis was performed on QoL as the primary outcome or not; thus, the sample size may not have been sufficient to find differences when not powered for QoL as the primary outcome. Thirdly, the methodological heterogeneity of the studies limited unbiased comparisons and quantitative syntheses, and the risk of bias was not calculated. More specific and standardised tools for assessing QoL in patients with AT are necessary.

AT is a problematic condition, both for the individual and healthcare providers. This review shows that AT patients have worse QoL than the general population and highlights the importance of recognising, assessing, and integrating QoL domains within the treatment paradigms and interventions to improve patient outcomes. It also shows the need for a new PROM for AT considered QoL. Moreover, this will provide health professionals with a better understanding of this condition that will indeed have a positive impact on AT patients’ management.

ACT: Autologous-Conditioned Plasma; AQoL-8D: assessment of quality of life-8-dimension; AT: Achilles tendinopathy; BMI: Body Mass Index; EQ-5D: EuroQol 5 dimensions; F: Female; FAOS: Foot and Ankle Outcome Score; KOA: Knee Osteoarthritis; KOOS: Knee Injury and Osteoarthritis Outcome Score; M: Male; OA: Osteoarthritis; PROM: Patient Reported Outcome; RA: Rheumatoid Arthritis; QoL: quality of life; SF-36: Short Form; TSK: Tampa Scale for Kinesiophobia; UoP-PFQ: University of Peloponnese Pain, Functionality and Quality of Life Questionnaire; VISA-A: Victorian Institute of Sport Assessment- Achilles questionnaire;

Acknowledgments

We would like to thank all the patients and volunteers who collaborate and continually support the activity and mission of our organisations.

Also, we would like to thank all the project partners who supported the writing of this manuscript: Barça Innovation Hub, Cambridge Nanomaterials Technology LTD, CELLINK, Eindhoven University of Technology, Fraunhofer, Fundació Clínic Barcelona, Gradocell, Leitat, University of Stuttgart, University of the Basque Country (UPV EHU) and Viscofan.

Finally, we would like to thank Rosa Maya Sciortino Contreras, who helped us to perform the quality appraisal and Dr. Patrick Du Souich, who supported the writing of this manuscript.

Authors’ contributions

JV conceived and designed the study and was in charge of overall direction and planning; NM and AP executed and led the completion of the project; NM and AP wrote the manuscript with support and revisions from JV and MB; JV and MB supervised the finding of this work; MS and GR revised the manuscript.

All authors discussed the results and have read and approved the final manuscript.

Funding

The submitted manuscript was funded by Horizon 2020 initiative.

Call: H2020-NMBP-TR-IND-2020-two-stage

Project: 952981 — TRiAnkle

Availability of data and materials

All data generated or analysed during this study are included in this published article

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

Not applicable.

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No competing interests reported.

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Psychosocial and individual factors affecting Quality of Life (QoL) in patients suffering from Achilles tendinopathy: A Systematic Review

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